Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off‑label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Risk assessment

All patients

1.1.1 Assess all patients to identify the risk of venous thromboembolism (VTE) and bleeding (see recommendation 1.1.2 for all medical patients, 1.1.5 for all surgical patients, 1.1.9 for all pregnant women and all women who gave birth or had a miscarriage or termination of pregnancy in the past 6 weeks, 1.8.1 for all people admitted to the critical care unit and 1.9.1 for all acute psychiatric patients). [2018]

People admitted to hospital

Medical patients

1.1.2 Assess all medical patients to identify the risk of VTE and bleeding:

As soon as possible after admission to hospital or by the time of the first consultant review

1.1.3 Balance the person's individual risk of VTE against their risk of bleeding when deciding whether to offer pharmacological thromboprophylaxis to medical patients. [2018]

1.1.4 If using pharmacological VTE prophylaxis for medical patients, start it as soon as possible and within 14 hours of admission, unless otherwise stated in the population-specific recommendations (see sections 1.4 to 1.9). [2018]

Surgical and trauma patients

1.1.5 Assess all surgical and trauma patients to identify the risk of VTE and bleeding:

As soon as possible after admission to hospital or by the time of the first consultant review

1.1.6 Balance the person's individual risk of VTE against their risk of bleeding when deciding whether to offer pharmacological thromboprophylaxis to surgical and trauma patients. [2018]

1.1.7 If using pharmacological VTE prophylaxis for surgical and trauma patients, start it as soon as possible and within 14 hours of admission, unless otherwise stated in the population-specific recommendations (see sections 1.10 to 1.15). [2018]

Reassessment of risk of VTE and bleeding

1.1.8 Reassess all medical, surgical and trauma patients for risk of VTE and bleeding at the point of consultant review or if their clinical condition changes. [2018]

Pregnant women and women who gave birth or had a miscarriage or termination of pregnancy in the past 6 weeks

1.1.9 Assess all women on admission to hospital or a midwife-led unit if they are pregnant or gave birth, had a miscarriage or had a termination of pregnancy in the past 6 weeks, to identify their risk of VTE and bleeding. Use a tool published by a national UK body, professional network or peer-reviewed journal. The most commonly used risk assessment tool was developed by the Royal College of Obstetricians and Gynaecologists[2]. [2018]

1.1.10 Reassess risk of VTE and bleeding, and assess the need for thromboprophylaxis for all women:

within 6 hours of giving birth, having a miscarriage or having a termination of pregnancy or

if their clinical condition changes and they:

are pregnant or

gave birth, had a miscarriage or had a termination of pregnancy within the past 6 weeks. [2018]

1.2 Giving information and planning for discharge

1.2.1 On admission ensure that people understand the reason for having a risk assessment for VTE and bleeding. [2018]

1.2.2 For people admitted to hospital who are at increased risk of VTE, give them and their family members or carers (as appropriate) verbal and written information on the following before offering VTE prophylaxis:

the person's risks and possible consequences of VTE

the importance of VTE prophylaxis and its possible side effects – for example, pharmacological prophylaxis can increase bleeding risk

how people can reduce their risk of VTE (such as keeping well hydrated and, if possible, exercising and becoming more mobile). [2018]

1.2.3 Be aware that heparins are of animal origin and this may be of concern to some people[3]. Discuss the alternatives with people who have concerns about using animal products, after discussing their suitability, advantages and disadvantages with the person. [2018]

1.2.4 As part of the discharge plan, give patients and their family members or carers (as appropriate) verbal and written information on:

the signs and symptoms of deep vein thrombosis (DVT) and pulmonary embolism

how people can reduce their risk of VTE (such as keeping well hydrated and, if possible, exercising and becoming more mobile)

the importance of seeking help if DVT, pulmonary embolism or other adverse events are suspected. [2018]

1.2.5 Give people discharged with VTE prophylaxis and their family members or carers (as appropriate) verbal and written information on:

the importance of using VTE prophylaxis correctly (including the correct administration and disposal of pharmacological prophylaxis)

the importance of continuing treatment for the recommended duration

the signs and symptoms of adverse events related to VTE prophylaxis

the importance of seeking help and who to contact if people have problems using VTE prophylaxis. [2018]

1.2.6 Ensure that people who are discharged with anti-embolism stockings:

understand the benefits of wearing them

understand the importance of wearing them correctly

understand the need to remove them daily for hygiene purposes

are able to remove and replace them, or have someone available who will be able to do this for them

know what to look for if there is a problem – for example, skin marking, blistering or discolouration, particularly over the heels and bony prominences

know who to contact if there is a problem

know when to stop wearing them. [2018]

1.2.7 Ensure that people who are discharged with pharmacological and/or mechanical VTE prophylaxis are able to use it correctly, or have arrangements made for someone to be available who will be able to help them. [2018]

1.2.8 Notify the person's GP if the person has been discharged with pharmacological and/or mechanical VTE prophylaxis to be used at home. [2018]

1.3 All patients

Mechanical prophylaxis

1.3.1 Do not offer anti-embolism stockings to people who have:

suspected or proven peripheral arterial disease

peripheral arterial bypass grafting

peripheral neuropathy or other causes of sensory impairment

any local conditions in which anti-embolism stockings may cause damage – for example, fragile 'tissue paper' skin, dermatitis, gangrene or recent skin graft

1.3.2 Ensure that people who need anti-embolism stockings have their legs measured and that they are provided with the correct size of stocking. Anti-embolism stockings should be fitted and patients shown how to use them by staff trained in their use. [2010]

1.3.3 Ensure that people who develop oedema or postoperative swelling have their legs re‑measured and anti-embolism stockings refitted. [2010]

1.3.7 Remove anti-embolism stockings daily for hygiene purposes and to inspect skin condition. In people with a significant reduction in mobility, poor skin integrity or any sensory loss, inspect the skin 2 or 3 times a day, particularly over the heels and bony prominences. [2010]

1.3.8 Monitor the use of anti-embolism stockings and offer assistance if they are not being worn correctly. [2010]

1.3.9 Stop the use of anti-embolism stockings if there is marking, blistering or discolouration of the skin, particularly over the heels and bony prominences, or if the person experiences pain or discomfort. If suitable, offer intermittent pneumatic compression as an alternative. [2010, amended 2018]

1.3.10 Do not offer intermittent pneumatic compression to people with a known allergy to the material of manufacture. [2010, amended 2018]

1.3.11 Advise the person to wear their device for as much time as possible. [2010, amended 2018]

Pharmacological prophylaxis

1.3.12 For pharmacological VTE prophylaxis in people under 18, follow the recommendations on apixaban, aspirin, dabigatran etexilate, fondaparinux sodium, low-molecular-weight heparin (LMWH) and rivaroxaban in this guideline. At the time of publication (March 2018), these drugs did not have a UK marketing authorisation for use in young people under 18 for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information. [2018]

Nursing care: early mobilisation and hydration

1.3.14 Encourage people to mobilise as soon as possible. [2010]

1.3.15 Do not allow people to become dehydrated unless clinically indicated. [2010]

People using antiplatelet agents

1.3.16 Consider VTE prophylaxis for people who are having antiplatelet agents for other conditions and whose risk of VTE outweighs their risk of bleeding. Take into account the risk of bleeding and of comorbidities such as arterial thrombosis.

If the risk of VTE outweighs the risk of bleeding, consider pharmacological VTE prophylaxis based on their condition or procedure.

If the risk of bleeding outweighs the risk of VTE, consider mechanical VTE prophylaxis. [2018]

People using anticoagulation therapy

1.3.17 Consider VTE prophylaxis for people at increased risk of VTE who are interrupting anticoagulant therapy. [2018]

1.4 Interventions for people with acute coronary syndromes or acute stroke or for acutely ill patients

Acute coronary syndromes

1.4.1 Be aware that people receiving anticoagulant drugs as part of their treatment for an acute coronary syndrome do not usually need VTE prophylaxis. See also recommendation 1.3.17. [2018]

Acute stroke patients

1.4.2 Do not offer anti-embolism stockings for VTE prophylaxis to people who are admitted for acute stroke. [2010, amended 2018]

1.4.3 Consider intermittent pneumatic compression for VTE prophylaxis for people who are immobile and admitted with acute stroke. If using, start it within 3 days of acute stroke. [2018]

1.4.4 Explain to the person admitted with acute stroke and their family members or carers (as appropriate) that intermittent pneumatic compression:

reduces the risk of DVT and may increase their chances of survival

will not help them recover from stroke, and there may be an associated increased risk of surviving with severe disability. [2018]

1.4.5 When using intermittent pneumatic compression for people who are admitted with acute stroke, provide it for 30 days or until the person is mobile or discharged, whichever is sooner. [2018]

Acutely ill medical patients

1.4.6 Offer pharmacological VTE prophylaxis for a minimum of 7 days to acutely ill medical patients whose risk of VTE outweighs their risk of bleeding:

1.5 Interventions for people with renal impairment

1.5.1 If using pharmacological VTE prophylaxis for people with renal impairment, choose either LMWH[4] or unfractionated heparin (UFH). [2018]

1.5.2 If needed, reduce the dose of LMWH[4] and UFH for people with renal impairment. Base the decision on multidisciplinary or senior opinion, or locally agreed protocols. [2018]

1.6 Interventions for people with cancer

1.6.1 Do not offer VTE prophylaxis to people with cancer who are receiving cancer-modifying treatments such as radiotherapy, chemotherapy or immunotherapy and who are mobile, except as outlined in recommendations 1.6.2 and 1.6.3, unless they are also at increased risk of VTE because of something other than the cancer. [2018]

1.6.2 Consider pharmacological VTE prophylaxis for people with myeloma who are receiving chemotherapy with thalidomide, pomalidomide or lenalidomide with steroids. Choose either:

1.6.3 Consider pharmacological VTE prophylaxis with LMWH[4] for people with pancreatic cancer who are receiving chemotherapy. [2018]

1.6.4 If giving VTE prophylaxis to people with cancer (see recommendations 1.6.2 and 1.6.3), continue for as long as they are receiving chemotherapy. [2018]

1.7 Interventions for people having palliative care

1.7.1 Consider pharmacological VTE prophylaxis for people who are having palliative care. Take into account temporary increases in thrombotic risk factors, risk of bleeding, likely life expectancy and the views of the person and their family members or carers (as appropriate):

1.7.4 Review VTE prophylaxis daily for people who are having palliative care, taking into account the views of the person, their family members or carers (as appropriate) and the multidisciplinary team. [2018]

1.8 Interventions for people admitted to critical care

1.8.1 Assess all people admitted to the critical care unit for risk of VTE and bleeding. [2018]

1.8.2 Provide LMWH[4] to people admitted to the critical care unit if pharmacological VTE prophylaxis is not contraindicated. For people with renal impairment, see recommendations 1.5.1 and 1.5.2. [2018]

1.8.3 Consider mechanical VTE prophylaxis for people admitted to the critical care unit if pharmacological prophylaxis is contraindicated based on their condition or procedure. [2018]

1.8.4 If using mechanical VTE prophylaxis for people admitted to the critical care unit, start it on admission and continue until the person no longer has reduced mobility relative to their normal or anticipated mobility. [2018]

1.9.2 Reassess all people admitted to an acute psychiatric ward for risk of VTE and bleeding at the point of consultant review or if their clinical condition changes. [2018]

1.9.3 Consider pharmacological VTE prophylaxis with LMWH[4] for people admitted to an acute psychiatric ward whose risk of VTE outweighs their risk of bleeding. [2018]

1.9.4 Consider pharmacological VTE prophylaxis with fondaparinux sodium[5] if LMWH[4] is contraindicated for people admitted to an acute psychiatric ward whose risk of VTE outweighs their risk of bleeding. [2018]

1.9.5 Continue pharmacological VTE prophylaxis for people admitted to an acute psychiatric ward until the person is no longer at increased risk of VTE. [2018]

1.10 Interventions when using anaesthesia

1.10.1 Consider regional anaesthesia for individual patients, in addition to other methods of VTE prophylaxis, as it carries a lower risk of VTE than general anaesthesia. Take into account the person's preferences, their suitability for regional anaesthesia and any other planned method of VTE prophylaxis. [2010]

1.10.2 If regional anaesthesia is used, plan the timing of pharmacological VTE prophylaxis to minimise the risk of epidural haematoma. If antiplatelet or anticoagulant agents are being used, or their use is planned, refer to the summary of product characteristics for guidance about the safety and timing of these in relation to the use of regional anaesthesia. [2010]

1.10.3 Do not routinely offer pharmacological or mechanical VTE prophylaxis to people undergoing a surgical procedure with local anaesthesia by local infiltration with no limitation of mobility. [2010]

1.11.3 Consider pre‑operative VTE prophylaxis for people with fragility fractures of the pelvis, hip or proximal femur if surgery is delayed beyond the day after admission. Give the last dose no less than 12 hours before surgery for LMWH[4] or 24 hours before surgery for fondaparinux sodium[5]. [2018]

1.11.4 Consider intermittent pneumatic compression for people with fragility fractures of the pelvis, hip or proximal femur at the time of admission if pharmacological prophylaxis is contraindicated. Continue until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility. [2018]

Upper limb orthopaedic surgery

1.11.15 Be aware that VTE prophylaxis is generally not needed if giving local or regional anaesthetic for upper limb surgery. [2018]

1.11.16 Consider VTE prophylaxis for people undergoing upper limb surgery if the person's total time under general anaesthetic is over 90 minutes or where their operation is likely to make it difficult for them to mobilise. [2018]

1.12 Interventions for people having elective spinal surgery or cranial surgery or people with spinal injury

1.12.3 If using LMWH[4] for people undergoing elective spinal surgery, start giving it 24–48 hours postoperatively according to clinical judgement, taking into account patient characteristics and surgical procedure. Continue for 30 days or until the person is mobile or discharged, whichever is sooner. [2018]

1.12.4 If needed, start LMWH[4] earlier than 24 hours after the operation for people undergoing elective spinal surgery. Base the decision on multidisciplinary or senior opinion, or a locally agreed protocol. [2018]

Cranial surgery

1.12.6 If using mechanical VTE prophylaxis for people undergoing cranial surgery, start it on admission. Choose either:

anti-embolism stockings or

intermittent pneumatic compression.

Continue for 30 days or until the person is mobile or discharged, whichever is sooner. [2018]

1.12.7 Consider adding pre‑operative pharmacological VTE prophylaxis with LMWH[4]. Give the last dose no less than 24 hours before surgery for people undergoing cranial surgery whose risk of VTE outweighs their risk of bleeding. [2018]

1.12.9 If needed, start LMWH[4] earlier than 24 hours after the operation for people undergoing cranial surgery. Base the decision on multidisciplinary or senior opinion, or a locally agreed protocol. [2018]

1.12.10 Do not offer pharmacological VTE prophylaxis to people with ruptured cranial vascular malformations (for example, brain aneurysms) or people with intracranial haemorrhage (spontaneous or traumatic) until the lesion has been secured or the condition has stabilised. [2018]

Spinal injury

1.12.12 Reassess risk of bleeding 24 hours after initial admission in people with spinal injury. [2018]

1.12.13 Consider adding pharmacological VTE prophylaxis with LMWH[4] 24 hours after initial admission for people with spinal injury who are not having surgery in the next 24–48 hours, if the benefit of reducing the risk of VTE outweighs the risk of bleeding. [2018]

1.12.14 Continue VTE prophylaxis in people with spinal injury for 30 days or until the person is mobile or discharged, whichever is sooner. [2018]

1.13 Interventions for people with major trauma

1.13.1 Offer mechanical VTE prophylaxis with intermittent pneumatic compression on admission to people with serious or major trauma. Continue until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility. [2018]

1.13.2 Reassess risk of VTE and bleeding in people with serious or major trauma whenever their clinical condition changes and at least daily. [2018]

1.13.3 Consider pharmacological VTE prophylaxis for people with serious or major trauma as soon as possible after the risk assessment when the risk of VTE outweighs the risk of bleeding. Continue for a minimum of 7 days. [2018]

1.14 Interventions for people having abdominal, thoracic or head and neck surgery

Continue until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility. [2018]

1.14.3 Add pharmacological VTE prophylaxis for a minimum of 7 days for people undergoing abdominal surgery whose risk of VTE outweighs their risk of bleeding, taking into account individual patient factors and according to clinical judgement. Choose either:

Head and neck surgery

Oral and maxillofacial surgery

1.14.11 Consider pharmacological VTE prophylaxis with LMWH[4] for a minimum of 7 days for people undergoing oral or maxillofacial surgery whose risk of VTE outweighs their risk of bleeding. [2018]

1.14.12 Consider mechanical VTE prophylaxis on admission for people undergoing oral or maxillofacial surgery who are at increased risk of VTE and high risk of bleeding. Choose either:

anti-embolism stockings or

intermittent pneumatic compression.

Continue until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility. [2018]

ENT surgery

1.14.13 Consider pharmacological VTE prophylaxis with LMWH[4] for a minimum of 7 days for people undergoing ears, nose or throat (ENT) surgery whose risk of VTE outweighs their risk of bleeding. [2018]

1.14.14 Consider mechanical VTE prophylaxis on admission for people undergoing ENT surgery who are at increased risk of VTE and high risk of bleeding. Choose either:

anti-embolism stockings or

intermittent pneumatic compression.

Continue until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility. [2018]

1.15 Interventions for people having cardiac or vascular surgery

Cardiac surgery

1.15.1 Consider mechanical VTE prophylaxis on admission for people who are undergoing cardiac surgery who are at increased risk of VTE. Choose either:

anti-embolism stockings or

intermittent pneumatic compression.

Continue until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility. [2018]

1.15.2 Consider adding pharmacological VTE prophylaxis for a minimum of 7 days for people who are undergoing cardiac surgery and are not having other anticoagulation therapy:

Vascular surgery

Open vascular surgery or endovascular aneurysm repair

1.15.3 Consider pharmacological VTE prophylaxis with LMWH[4] for a minimum of 7 days for people who are undergoing open vascular surgery or major endovascular procedures, including endovascular aneurysm repair whose risk of VTE outweighs their risk of bleeding. [2018]

1.15.4 Consider mechanical VTE prophylaxis on admission for people who are undergoing open vascular surgery or major endovascular procedures, including endovascular aneurysm repair, if pharmacological prophylaxis is contraindicated. Choose either:

anti-embolism stockings or

intermittent pneumatic compression.

Continue until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility. [2018]

Lower limb amputation

1.15.5 Consider pharmacological VTE prophylaxis with LMWH[4] for a minimum of 7 days for people who are undergoing lower limb amputation whose risk of VTE outweighs their risk of bleeding. [2018]

1.15.6 Consider mechanical VTE prophylaxis with intermittent pneumatic compression on the contralateral leg, on admission, for people who are undergoing lower limb amputation and if pharmacological prophylaxis is contraindicated. [2018]

1.15.7 For people undergoing lower limb amputation, continue mechanical VTE prophylaxis until the person no longer has significantly reduced mobility relative to their anticipated mobility. [2018]

Varicose vein surgery

1.15.8 Be aware that VTE prophylaxis is generally not needed for people undergoing varicose vein surgery where:

1.15.11 If using anti-embolism stockings for people undergoing varicose vein surgery, continue until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility. [2018]

1.16 Interventions for pregnant women and women who gave birth or had a miscarriage or termination of pregnancy in the past 6 weeks

1.16.1 Consider LMWH[4] for all women who are admitted to hospital or a midwife-led unit if they are pregnant or gave birth, had a miscarriage or had a termination of pregnancy in the past 6 weeks, and whose risk of VTE outweighs their risk of bleeding. [2018]

1.16.2 Do not offer VTE prophylaxis to women admitted to hospital or a midwife-led unit who are in active labour. [2018]

1.16.4 If using LMWH[4] in pregnant women, start it as soon as possible and within 14 hours of the risk assessment being completed and continue until the woman is no longer at increased risk of VTE or until discharge from hospital or the midwife-led unit. [2018]

1.16.5 If using LMWH[4] in women who gave birth or had a miscarriage or termination of pregnancy, start 4–8 hours after the event unless contraindicated and continue for a minimum of 7 days. [2018]

1.16.6 Consider combined prophylaxis with LMWH[4] plus mechanical prophylaxis for pregnant women or women who gave birth or had a miscarriage or termination of pregnancy in the past 6 weeks and who are likely to be immobilised, or have significantly reduced mobility relative to their normal or anticipated mobility for 3 or more days after surgery, including caesarean section:

If intermittent pneumatic compression is contraindicated, use anti-embolism stockings.

Continue until the woman no longer has significantly reduced mobility relative to her normal or anticipated mobility or until discharge from hospital. [2018]

Terms used in this guideline

Admission

Admission in the context of this guideline refers to admission as an inpatient, where a bed is provided for 1 or more nights, or admission as a day patient, where a bed is provided for a procedure including surgery or chemotherapy but not for an overnight stay.

Discharge

Discharge in the context of this guideline refers to discharge from hospital as an inpatient or after a day procedure.

Intermittent pneumatic compression

A method of prophylaxis that includes an air pump and inflatable garments in a system designed to improve venous circulation in the lower limbs of people at risk of DVT or pulmonary embolism. The inflation–deflation cycle of intermittent pneumatic compression therapy simulates the thigh, calf and foot's normal ambulatory pump action increasing both the volume and rate of blood flow, eliminating venous stasis and replicating the effects of the natural muscle pump. Intermittent pneumatic compression devices can be thigh- or knee-length sleeves that are wrapped around the leg, or a garment that can be wrapped around or worn on the foot that is designed to mimic the actions of walking.

Lower limb immobilisation

Any clinical decision taken to manage the affected limb in a way that would prevent normal weight-bearing status or use of that limb, or both.

Renal impairment

People with an estimated glomerular filtration rate (eGFR) of less than 30 ml/min/1.73 m2. For more detailed information on renal impairment, see NICE's guideline on chronic kidney disease in adults.

Significantly reduced mobility

People who are bed bound, unable to walk unaided or likely to spend a substantial proportion of their day in bed or in a chair.

[2] Reproduced from: Royal College of Obstetricians and Gynaecologists. Reducing the risk of venous thromboembolism during pregnancy and the puerperium. Green-top Guideline No. 37a. London: RCOG, 2015, with the permission of the Royal College of Obstetricians and Gynaecologists.

[4] At the time of publication (March 2018), LMWH did not have a UK marketing authorisation for use in young people under 18 for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

[5] At the time of publication (March 2018), fondaparinux sodium did not have a UK marketing authorisation for use in young people under 18 for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

[7] At the time of publication (March 2018), rivaroxaban did not have a UK marketing authorisation for use in young people under 18 for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

[8] At the time of publication (March 2018), apixaban did not have a UK marketing authorisation for use in young people under 18 for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

[9] At the time of publication (March 2018), dabigatran etexilate did not have a UK marketing authorisation for use in young people under 18 for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.